care of the unconscious patient acute care day case studies assessing gcs looking after the...

Care of the Unconscious Patient Acute Care Day

Case StudiesAssessing GCSLooking after the Unconscious Patient

Assessing Consciousness

• Using GCS• Prevention of secondary complications of

Coma• Safely managing comatose patients

Principles of assessing ConsciousnessGlasgow Coma Scale

Eye Response4 Eyes open spontaneously3 Eyes open to verbal Command2 Eyes open to Pain1 No eye opening

Motor Response6 Obeys Commands5 Localises to Pain4 Withdraws to pain3 Flexes to pain2 Extension to pain1 No Motor Response

Verbal Response5 Orientated4 Confused3 Inappropriate Words2 Incomprehensible Sounds1 No Verbal Response

Assessing GCS

• Score should always be documented as the 3 components and not just a total

• Needs to be re-assessed regularly• Make sure stimulus is applied above the

clavicle when assessing – in case there is a high spinal lesion

Case 1

Acute Respiratory Care Day

Case 1

• 30 year old• Found by shopkeeper when opening up

shop sleeping in shop doorway, when asked to move on seemed a bit confused,

• Became progressively more drowsy and refused to move from doorway so ambulance called.

• You are called to assess him in A&E

Case 1 (1)

What are you going to do?

Assessment

• A• B• C• D• E

A and B

• Talking (confused)• Respiratory rate 20 breaths per minute• Oxygen saturations 97% on air• Trachea central• Normal Breath sounds

C

• Good Capillary return• Pulse 120bpm• BP 110/65 mmHg

D and E

• Assess GCS (Chart on your chart)

• Nothing else found on exposure

• Specifically no signs of trauma

• Sweaty

Case 1 D and E

Case 1 What Now?

• Further examination?• Further Investigations?• Further Management?

Case 1

• Nurse calls you back to see him because she is concerned about his condition

Case 1 (2)

Case 1 (2nd set obs)

Case 1 What is his coma scale now?

• Chart his coma scale now on your paper chart

• What further assessment do you need to do?– A – slight snoring, but has he still got protective

reflexes– B- SaO2 95% on air, Air entry still OK– C

• pulse 115

• Bp 140/85

• What further investigations does he need?• Potential causes for his acute change?

What Measures do you need to take to ensure safety of unconscious patient?

• Airway protection• Positioning• Preventing pressure sores• Protecting neck and limbs from injury• Corneal protection

Clinical Decisions in the Unconscious patient

• Combination of diagnostic steps and treatment decisions

• Pragmatic assessment of adequacy of medical support

• Find treatable disorder• Initial care, diagnosis and treatment of

reversible pathology• Think about safety for transfer of patients• Consent for treatment / Incapacity Forms

Prevent complications

• Aspiration• Pressure Sores• Dehydration• Malnutrition• Secondary brain injury• Nosocomial infections• Eye and mouth care• DVT/PE• Rhabdomyolysis

Case 2

• 33 year old man, has been found at bottom of flight of stairs in his close,

• He has blood on the back of his head, and the ambulance crew have said that there was some blood coming from his left ear when they arrived at the scene

Case 2 – Chart his GCS

Case 3: Presentation

• 18 year old• 3 week history of dental abscess on left

upper molar• Too afraid to go to dentist so took his

mother’s co-codamol tablets • Fever for 1 week,• Found by mother in bedroom, could not

wake him up this morning, called ambulance.

Case 3: Initial Assessment:

• A – Airway Clear (how do you test for that?)– No cough or gag reflex

• B– SaO2 96% on air,– Air entry both sides

• C– P 130 Sinus rhythm– Bp 85/32– Warm, vasodilated,

Case 3 D and E

Case 3 GCS

What next?

Any investigations?

Case 3: What next?

• Any investigations? • Temp 40.5 C• WCC 25• CRP 450

• CT -

Questions?